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Anatomic Footprint of the Direct Head of the Rectus Femoris Origin: Cadaveric Study and Clinical Series of Hips After Arthroscopic Anterior Inferior Iliac Spine/Subspine Decompression

Published:October 21, 2013DOI:https://doi.org/10.1016/j.arthro.2013.08.023

      Purpose

      The purposes of this study were to define the anatomy of the anterior inferior iliac spine (AIIS) and its relation to the footprint of the rectus femoris tendon and to evaluate on the clinical outcomes after AIIS/subspine decompression.

      Methods

      The rectus origin was dissected and detached in 11 male cadaveric hips with a mean age of 54.3 ± 14.3 years (range, 33 to 74 years). The proximal-distal and medial-lateral extent of the footprint and its relation to the AIIS and acetabular rim were evaluated, with the 12-o'clock position defined as directly lateral at the insertion of the indirect head of the rectus tendon and the 1- to 6-o'clock positions defined as anterior acetabular positions. To assess the safety and efficacy of subspine decompression for AIIS deformity, clinical correlation of a series of 163 AIIS decompressions (mean age, 27.8 years; age range, 14 to 52 years) performed from January 2011 to January 2012 was completed, and outcome scores, strength deficits, and ruptures were assessed by manual muscle testing and postoperative radiographs. All patients presented with symptomatic FAI with proximal femoral and/or acetabular deformity and type 2 (131 hips) or type 3 (32 hips) AIIS morphology as defined by Hetsroni et al.

      Results

      The mean proximal-distal and medial-lateral distances for the rectus origin footprint were 2.2 ± 0.1 cm (range, 2.1 to 2.4 cm) and 1.6 ± 0.3 cm (range, 1.2 to 2.3 cm), respectively. There was a characteristic bare area at the anteromedial AIIS. On the clock face, the lateral margin (1-o'clock to 1:30 position) and medial margin (2-o'clock to 2:30 position) of the AIIS and the indirect head of the rectus (12 o'clock) were consistent for all specimens. In the clinical series, 163 AIIS decompressions were performed for symptomatic subspine impingement. The mean modified Harris Hip Score was 63.1 points (range, 21 to 90 points) preoperatively compared with 85.3 points (range, 37 to 100 points) at a mean follow-up of 11.1 ± 4.1 months (range, 6 to 24 months) (P < .01). Short Form 12 scores improved significantly from a mean of 70.4 (range, 34 to 93) preoperatively to a mean of 81.3 (range, 31 to 99) postoperatively (P < .01). The mean pain score on a visual analog scale also improved significantly from a mean of 4.9 (range, 0.1 to 8.6) preoperatively to a mean of 1.9 (range, 0 to 7.8) postoperatively (P < .01). The mean alpha angle improved from 61.5° (range, 35° to 90°) preoperatively to 49° (range, 35° to 63°) postoperatively on anteroposterior radiographs and from 71° (range, 45° to 90°) preoperatively to 44.3° (range, 37° to 60°) postoperatively on lateral radiographs. No short- or long-term hip flexion deficits or rectus femoris avulsions were noted with up to 2 years' follow-up.

      Conclusions

      The origin of the rectus femoris tendon is broad on the AIIS and protective against direct head detachment with subspine decompression. This broad origin and consistent bare area anteromedially on the AIIS can be readily used by surgeons to perform a safe AIIS resection in cases of symptomatic impingement. Arthroscopic subspine decompression in addition to osteoplasty for symptomatic cam- and/or pincer-type FAI deformities can reliably improve outcome scores without significant hip flexion deficits or AIIS/rectus femoris avulsions.

      Clinical Relevance

      The direct head of the rectus tendon has a broad insertion on the AIIS, and an area devoid of tendon provides a “safe zone” for subspine decompression in cases of symptomatic AIIS impingement.
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      References

        • Ito K.
        • Minka II, M.A.
        • Leunig M.
        • Werlen S.
        • Ganz R.
        Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset.
        J Bone Joint Surg Br. 2001; 83: 171-176
        • Leunig M.
        • Beck M.
        • Woo A.
        • Dora C.
        • Kerboull M.
        • Ganz R.
        Acetabular rim degeneration: A constant finding in the aged hip.
        Clin Orthop Relat Res. 2003; : 201-207
        • Ganz R.
        • Parvizi J.
        • Beck M.
        • Leunig M.
        • Nötzli H.
        • Siebenrock K.A.
        Femoroacetabular impingement: A cause for osteoarthritis of the hip.
        Clin Orthop Relat Res. 2003; : 112-120
        • Lavigne M.
        • Parvizi J.
        • Beck M.
        • Siebenrock K.A.
        • Ganz R.
        • Leunig M.
        Anterior femoroacetabular impingement: Part I. Techniques of joint preserving surgery.
        Clin Orthop Relat Res. 2004; : 61-66
        • Ganz R.
        • Leunig M.
        • Leunig-Ganz K.
        • Harris W.H.
        The etiology of osteoarthritis of the hip.
        Clin Orthop Relat Res. 2008; 466: 264-272
        • Taneja A.K.
        • Bredella M.A.
        • Torriani M.
        Ischiofemoral impingement.
        Magn Reson Imaging Clin N Am. 2013; 21: 65-73
        • Stafford G.H.
        • Villar R.N.
        Ischiofemoral impingement.
        J Bone Joint Surg Br. 2011; 93: 1300-1302
        • Macnicol M.F.
        • Makris D.
        Distal transfer of the greater trochanter.
        J Bone Joint Surg Br. 1991; 73: 838-841
      1. Leunig M, Ganz R. Relative neck lengthening and intracapital osteotomy for severe Perthes and Perthes-like deformities. Bull NYU Hosp Jt Dis 2011;69(suppl 1):S62-S67.

        • Larson C.M.
        • Kelly B.T.
        • Stone R.M.
        Making a case for anterior inferior iliac spine/subspine hip impingement: Three representative case reports and proposed concept.
        Arthroscopy. 2011; 27: 1732-1737
        • Hetsroni I.
        • Larson C.M.
        • Dela Torre K.
        • Zbeda R.M.
        • Magennis E.
        • Kelly B.T.
        Anterior inferior iliac spine deformity as an extra-articular source for hip impingement: A series of 10 patients treated with arthroscopic decompression.
        Arthroscopy. 2012; 28: 1644-1653
        • Matsuda D.K.
        • Calipusan C.P.
        Adolescent femoroacetabular impingement from malunion of the anteroinferior iliac spine apophysis treated with arthroscopic spinoplasty.
        Orthopedics. 2012; 35: e460-e463
        • Hetsroni I
        • Kelly BT
        • Bedi A
        • Poultsides L
        • Larson CM
        Anterior inferior iliac spine morphology correlates with hip range of motion in patients with impingement: A concept supported by a CT-basedclassification system and a dynamic hip model.
        Clin Orthop Relat Res. 2013; 471: 2497-2503
        • Milankov M.Z.
        • Harhaji V.
        • Gojković Z.
        • Drapsin M.
        Heterotopic ossification following surgical treatment of avulsion fracture of the anterior inferior iliac spine.
        Med Pregl. 2011; 64: 593-596
        • Ilizaliturri Jr., V.M.
        • Byrd J.W.
        • Sampson T.G.
        • et al.
        A geographic zone method to describe intra-articular pathology in hip arthroscopy: Cadaveric study and preliminary report.
        Arthroscopy. 2008; 24: 534-539
        • Philippon M.J.
        • Stubbs A.J.
        • Schenker M.L.
        • Maxwell R.B.
        • Ganz R.
        • Leunig M.
        Arthroscopic management of femoroacetabular impingement: Osteoplasty technique and literature review.
        Am J Sports Med. 2007; 35: 1571-1580
        • Pan H.
        • Kawanabe K.
        • Akiyama H.
        • Goto K.
        • Onishi E.
        • Nakamura T.
        Operative treatment of hip impingement caused by hypertrophy of the anterior inferior iliac spine.
        J Bone Joint Surg Br. 2008; 90: 677-679
        • Zaltz I.
        • Kelly B.T.
        • Hetsroni I.
        • Bedi A.
        The crossover sign overestimates acetabular retroversion.
        Clin Orthop Relat Res. 2013; 471: 2463-2470
        • Resnick J.M.
        • Carrasco C.H.
        • Edeiken J.
        • Yasko A.W.
        • Ro J.Y.
        • Ayala A.G.
        Avulsion fracture of the anterior inferior iliac spine with abundant reactive ossification in the soft tissue.
        Skeletal Radiol. 1996; 25: 580-584
        • Linni K.
        • Mayr J.
        • Höllwarth M.E.
        Apophyseal fractures of the pelvis and trochanter minor in 20 adolescents and 2 young children.
        Unfallchirurg. 2000; 103: 961-964
        • Schothorst A.E.
        Avulsion fractures of the inferior-anterior iliac spine.
        Arch Chir Neerl. 1978; 30: 55-59
        • Gamradt S.C.
        • Brophy R.H.
        • Barnes R.
        • Warren R.F.
        • Thomas Byrd J.W.
        • Kelly B.T.
        Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football.
        Am J Sports Med. 2009; 37: 1370-1374